Nokea
Which clinical manifestations should the nurse expect to assess in a client diagnosed with an overdose of a cholinergic agent?
- A. Dry mucous membranes.
- B. Urinary incontinence.
- C. Central nervous system (CNS) depression.
- D. Seizures.
- E. Skin rash.
Correct Answer: B,C,D
Rationale: Cholinergic overdose (e.g., organophosphates) causes urinary incontinence (B), CNS depression (C), and seizures (D) due to excessive acetylcholine. Dry mucous membranes and skin rash are not typical.
You may also like to solve these questions
The nurse is caring for an older adult in the emergency department with moderate hypothermia. Which of the following actions should the nurse take? Select all that apply.
- A. Apply external heat with a heating blanket to the client's trunk.
- B. Actively rewarm the extremities first, followed by the client's trunk.
- C. Use extracorporeal rewarming methods such as cardiopulmonary bypass or hemodialysis.
- D. Monitor for fluid, electrolyte, and metabolic abnormalities.
- E. Administer ordered medications at spaced longer intervals.
- F. Administer room temperature intravenous (IV) fluids for core rewarming.
Correct Answer: A,D,F
Rationale: Applying heat to the trunk (A), monitoring electrolytes (D), and using room-temperature IV fluids (F) are appropriate for moderate hypothermia. Rewarming extremities first (B) risks core afterdrop, extracorporeal methods (C) are for severe cases, and altering medication intervals (E) lacks evidence.
Which of the following interventions would be most effective in preventing the development of acute respiratory distress syndrome (ARDS)?
- A. Teaching cigarette smoking cessation.
- B. Maintaining adequate serum potassium levels.
- C. Monitoring clients for signs of hypercapnia.
- D. Replacing fluids adequately during hypovolemic states.
Correct Answer: D
Rationale: Adequate fluid replacement in hypovolemia prevents shock, a major ARDS trigger. Smoking cessation, potassium levels, and hypercapnia monitoring are less directly related to ARDS prevention.
The nurse has an order to administer 2 oz of lactulose (Cephulac) to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer?
Correct Answer: 60 mL
Rationale: 2 oz = 60 mL (1 oz = 30 mL). Thus, the nurse should administer 60 mL of lactulose.
Which of the following therapeutic classes of drugs is used to treat tachycardia and angina in a client with pheochromocytoma?
- A. Angiotensin-converting enzyme (ACE) inhibitors.
- B. Calcium channel blockers.
- C. Beta blockers.
- D. Diuretics.
Correct Answer: C
Rationale: Beta blockers reduce tachycardia and angina in pheochromocytoma by blocking catecholamine effects on the heart.
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) accurately reflects the client's rapid tiring due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported by the symptoms described.